Order International CallBack

Name: (Person, Company or Organization)
Contact Person:
Email:	Telephone:	Fax:
Street Address:		Apartment/Suite Number:
City:		State:
Zip/Postal Code:		Country:
Payment Information: Credit Card Cash with Credit Card Guarantee Pre-Paid/Wire Transfer
Cardholder's Name:
Credit Card Type: Visa Mastercard American Express Diners Club NOTE: All credit card accounts are checked for validity. Please allow 48 to 72 hours for processing new accounts.
Credit Card Number:	Expiration Date:
I hereby authorize GLOBALTEL of Boca Raton, Florida, USA, to bill my credit card for all charges generated by my account. I agree to this method of payment, and agree that all sales are final, during the period of time that I subscribe to the services provided by GLOBALTEL. I further agree to promptly notify GLOBALTEL if my credit card is canceled or will be unavailable to be charged for any reason. (ATTACH COPY OF FRONT OF CREDIT CARD OR RECENT CREDIT CARD BILL). Agreed to by (Cardholder Signature Only): _______________________________________________________.

Name of Authorized User (Optional)	User's Phone Number (Your Callback Number)	Access Number (Assigned by GlobalTel)	Security Code (PIN)
		+ (561)
		+ (561)
		+ (561)
		+ (561)
		+ (561)
		+ (561)

Language choice for voice prompts (please check one):
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Special Instructions:

Please print this form out, fill and sign, then fax to:

MandL InfoServ Corporation
No.70, Xin Xiang, Wu Lao Cun, Nanjing, P.R. China
Tel: [86] (25) 452-9626 * Fax: [86] (25) 452-9031